Wrong Site Surgery Performed by ENT

In 2010, an ENT performed a tongue tie release on a 5 years old child who was supposed to undergo a tongue lesion biopsy (apparently 1cm in size over the central dorsal tongue). Tongue tie release was NOT consented for nor discussed with the parents who expected a tongue biopsy to be performed instead. In the investigative report performed by the Department of Public Health:

"When the surgeon was asked whether he examined the patient in the preop area prior to the surgery, he stated, "Usually, I don't examine anybody. I sometimes visit... In this case, there was no time to do a pre-operative visit. From now on, I need to see the patient prior to the surgery." [link]

According to the record, time-out WAS performed. Consent WAS in the chart for a tongue lesion biopsy. Records indicated that all mandated check-lists and time-outs were performed.

So what happened?

1) Surgeon Error: Let's face it... the surgeon made a mistake. Ultimately, it is his responsibility to ensure that the procedure goes smoothly which by definition means doing the correct procedure.

Seeing patients before surgery probably would have prevented this error. Not seeing the patient prior to surgery is not good practice.

Even if a surgeon employs a nurse practitioner or a physician assistant to see patients for him in the office or in the hospital, before any surgery, he personally should examine and discuss the upcoming surgery with all patients.

As an aside, at least once per week, I have patients calling who desire to schedule surgery without wanting to see me first for a consultation appointment. There are many reasons why I mandate that a patient MUST first be personally seen by me in the office PRIOR to any surgery scheduling. Preventing this scenario is one good reason why.

2) Nursing Error??? If the nurses knew what procedure was supposed to be done (according to the report, they did)... they should have spoken up! If they were too afraid to speak up, they should have contacted management to speak up for them... or ask the anesthesiologist to say something.

After all, patient welfare supersedes all else. Having wrong site surgery is the exact opposite.

However, to be fair in this particular situation, I do not believe the nurses knew what the surgeon was doing. Why???

The procedure was being done inside the mouth and a small child's mouth at that... honestly, nobody except the surgeon and possibly the anesthesiologist can really see what the surgeon is doing. The instruments used for tongue tie release is very similar to what would be used for tongue lesion biopsy.

3) Time-Out and Check-List Error: In a typical day, there are so many time-outs and check-lists being performed that it starts to get muted into background noise. It's just like the alarms and blinking lights that I imagine an instrument panel of a sophisticated machine would be for somebody who stares at it all day, everyday. You hear/see it... but than you don't hear/see it.

What people notice are sounds that are unusual for a given situation.

For example, cars make all sorts of noises when being turned on and moving somewhere. However, most people don't actually "hear" the sounds being produced by the car because of our lack of attention to it, because it is repetitive and continuous.

However, if one day, the engine starts knocking, that certainly gets a driver's attention and remembered.

Time-outs and check-lists suffer from inattention... even if performed.

They are a wonderful tool, but utterly undependable for long-term use.

So what would work given it must be done per regulations??? My suggestion would be to mix it up to prevent it from becoming "background" noise.

Have the time-out performed by different members of the surgical staff on every case rather than the same person. Ring a bell before doing time-out one time. On another time, have everyone dance a short jig before doing it. Whatever is done, do NOT make it repetitive which otherwise risks being inadvertently ignored.

The key is to make it different and notable each and every time in order to focus attention and prevent the task from becoming muted into the background.

Source:
CA Fines 14 Hospitals for Medical Errors. Health Leaders Media 8/31/12

Reference:
California Human and Health Resources Department of Public Health Report. 5/18/11

Bi-Lobed Zenker's Diverticulum

In the not so distant past, I saw a patient who suffered from a bi-lobed Zenker's Diverticulum. Zenker's diverticulum for those who don't know is the abnormal development of a pouch in the throat causing symptoms of phlegm in the throat, food regurgitation, swallowing difficulties, and aspiration.

Most Zenker's Diverticulum is composed of a single central pouch. However, there are more rare varieties such as this bi-lobed pouch seen on barium swallow.

However, at time of surgery (endoscopic staple diverticulostomy), the bi-lobed nature of the pouch essentially disappeared.

Video of how the surgery is performed:

Financial Issues with Emergency Room Specialist Care

Imagine this scenario... A young child is playing in the yard when her pet dog bites her face. Bleeding, the child is rushed to the emergency room and the emergency room doctor offers to suture up the child's face.

The next question a parent will probably ask (or demand) is the desire for a plastic surgeon to suture the face instead of the emergency room doctor.

As such, the plastic surgeon is called in and sutures up the face beautifully.

The child and family goes home and that's when the financial nightmare begins...

The plastic surgeon bills the family for $2,000 for services rendered in the emergency room. The plastic surgeon does NOT participate with their health insurance plan and being a non-participating provider, the bill for care provided is directly sent to the child's family.

Outrageous?

Unfortunately, it is not unusual... and there are lawsuits now pending both against specialist physicians as well as against patients regarding who pays the medical bills.

Here is an article portraying a hand surgeon who has sued numerous patients regarding just this scenario. Most specialists will either write-off or accept any amount after being sent to collection.

Background

If a patient has a medical problem, a call to the medical office is made to see the doctor. However, before the appointment is made, both the patient and office checks to ensure the visit will be covered by insurance. If not, a call to a different medical office is made until one that participates with the patient's insurance is found. However, if the patient decides to see a physician who does NOT participate with his health insurance company, he will be responsible for the entire bill (the office visit will not be covered by insurance).

The same is true for outside specialists called into the emergency room. These outside medical specialists participate only with certain insurances. As such, if they perform services on a patient whose health insurance does not cover that particular medical specialist, the patient will get the entire bill.

Emergency room care IS covered by insurance... because it is an "emergency," but services performed ONLY by the emergency room staff applies. NOT services by outside specialists called in.

What to Do?

So what is a patient to do in order to avoid a surprising large bill?

Ideally, have all services performed by emergency room staff and avoid services by outside specialists. If it is not life-threatening (like a facial dog-bite... ugly, but not life-threatening), have the emergency room doctor do all he can. Than follow-up as an outpatient with a specialist who participates with your health insurance plan.

If an outside specialist MUST be called in, ask whether this specialist participates with your health insurance plan. If not, ask how much the specialist will charge for services rendered. Be aware, if the outside specialist actually comes into the hospital, a consultation fee will be charged (typically around $100-$200). If a procedure is performed, a procedure charge will be present (hundreds to thousands of dollars).

A patient can request whether there is a different doctor who can be contacted should the specialist on-call not participate with his/her health insurance plan. However, be aware that typically only ONE doctor per specialty is on-call to the emergency room at any given time and as such, an alternative doctor may not be available.

Once you are aware of the charges, you as the patient needs to decide whether to proceed with specialist care or not.

Be aware that the insurance coverage issues also applies for specialist consultations during a hospitalization and not just in the emergency room.

Bottom Line

Simply going to the emergency room does not mean all medical services will be covered by insurance, especially services provided by a medical specialist.

If specialist care is required in the emergency room, just ask whether the specialist participates with your health insurance plan, because if not, be aware that you directly will get a bill.

That's just how the medical system is set up currently.

ENT Sued for Malpractice for Hearing Loss Due to Acoustic Neuroma

A patient has sued an ENT for failing to workup an asymmetric sensorineural hearing loss (nerve hearing loss greater in one ear compared to the opposite ear) that allegedly deviated from standard of care that ultimately led to permanent hearing damage and facial paralysis.

Since January 2008, the plaintiff saw the defendant ENT who performed 3 audiograms that revealed an asymmetric sensorineural hearing loss. In 2010, the plaintiff suffered a sudden sensorineural hearing loss at which time an MRI scan of the head was performed revealing a "large" acoustic neuroma (benign tumor of the hearing nerve).

Resection of this tumor resulted in a visible facial droop, permanent hearing loss, and cognitive deficits due to partial removal of brain tissue.

According to plaintiff, had the ENT performed MRI scan when asymmetric sensorineural hearing loss was first detected (presumably back in 2008), he never would have suffered from these defects.

Read about the case here.

Normally, if and when asymmetric sensorineural hearing loss is first detected, some type of workup is typically performed (auditory brainstem response and/or MRI scan of the head) unless there are extenuating factors present in the history. Such extenuating factors include old age and/or significant loud noise history that may lead to asymmetric hearing loss such as shooting (which often causes left greater than right nerve damaged hearing loss in right-handed shooters).

Apparently THREE audiograms were performed over time. If there was progressive worsening of the asymmetric sensorineural hearing loss, than MRI should have been performed and/or at the very least an auditory brainstem response testing (ABR). IF the audiograms showed stable asymmetry over time, it can be argued that absolutely no further workup is needed.

The key question in this case is had the defendant ENT obtained an MRI in 2008 when asymmetric sensorineural hearing loss was first detected, the acoustic neuroma would have been discovered earlier thereby preventing the permanent hearing loss he later suffered in 2010 along with facial paralysis and cognitive defects that occurred after surgical resection.

A couple problems with this line of reasoning:

1) Acoustic neuromas grow at a rate of 1mm per year on average. As such, if the acoustic neuroma was large in 2010... it most certainly was large in 2008 being only 2mm smaller.
2) As such, surgical resection of the "large" acoustic neuroma had it been performed in 2008 probably would have resulted in the same outcome of permanent hearing loss, facial paralysis, and cognitive defects.

Furthermore, had the MRI been performed back in 2008 revealing the tumor, the options that would have been presented to the defendant patient would be:

1) Surgery
2) Radiation
3) Observe

Given it is established that the acoustic neuroma was large even in 2008, any type of intervention whether surgery or radiation, most certainly would put at risk the facial nerve which runs alongside the acoustic neuroma. Permanent facial paralysis and hearing loss most certainly is not an uncommon outcome after intervention.

One could even argue that in all likelihood, ALL the defendants current complaints would have occurred 2 years more quickly had the MRI scan of the head and subsequent intervention been performed.

Observation would have only lead to the current sequence of events.

As such, did malpractice occur?

I don't think so.

Should the defendant ENT have ordered the MRI scan of the head back in 2008 when an audiogram he obtained showed the asymmetric sensorineural hearing loss?

Probably though this might be debatable depending on patient's prior noise history and exact audiogram findings. Most definitely if the audiograms revealed a progressive worsening of the asymmetry over time. Most likely not if the audiograms remained the same over time.

Would knowing there was an acoustic neuroma present in 2008 have changed the patient's ultimate outcome?

Probably not.

Source:
Couple sues physician for medical malpractice. The West Virginia Record 7/10/12

Creative Ways to Wear a Scarf for Patients with a Trach or Ugly Neck Scar

[Watch the video below!!!]

Given I operate on the neck not uncommonly... a common fear for a patient is how the incision will look afterwards. For a simple neck mass excision, the incision almost always heals just fine to the point nobody will notice the scar.

However, this concern is multiplied a hundred-fold when a patient undergoes a tracheostomy (hole in neck) for severe obstructive sleep apnea or for some other airway reason. It could even be a laryngectomy where the entire voicebox is removed for cancer reasons. 

Who wants everybody to know that there's a hole in the neck... especially for a woman??? Even if there's no hole, sometimes the scar IS noticeable, especially after thyroidectomy, and therefore undesirable.

Scarring from an incision can potentially be addressed with dermatologic procedures, but if no surgery is desired and honestly, what really can be done with a hole defect in the neck... it really boils down to a scarf of some kind to obstruct the neck from causal view.

I mistakenly thought there's only 2 ways to wear a scarf around the neck.

The video below shows 25 ways to wear a scarf! Even if a patient or an individual decides NOT to wear a scarf ever... you should STILL watch the video. The video editing is AMAZING!!!

The actress in the video is Wendy Nguyen who is a prolific fashion blogger who my wife pointed out to me one day.

US Gymnast Maroney Suffers Nasal Fracture

World vault champion McKayla Maroney on the US gymnastics team suffered a nasal fracture during pre-meet training when she over-rotated at the end of a tumbling run and fell hard earlier this month. She also suffered a concussion. A visit to the ER revealed her injuries. Apparently no surgical intervention was pursued.

This case illustrates that most nasal and even facial fractures do NOT require surgical repair.

The key elements that lead towards a decision for facial and/or nasal fracture surgery are the following (not all-inclusive, but general pointers):

- Any functional deficit including inability to open and close the jaw.
- Change in your occlusion (the way your teeth come together).
- Double vision (blurry vision does not count).
- Cosmetic deformity due to nasal/facial fracture (bruising and swelling does not count).
- Nasal obstruction not due to swelling.

The two main specialties able to assess whether surgery is required or not is ENT and Plastic Surgery as well as some oral surgeons.

Source:
Maroney suffers concussion, nasal fracture. ESPN 6/10/12

Motley Crue Bassist Facing Sinus Surgery

Dr. Feelgood may be just a song by Motley Crue, but the band's bassist, Nikki Sixx may be facing sinus surgery.

Per his twitter comment on June 27, 2012:

"Spent a lot of the day at the doctors. The 80s and the damage done. Yes the sinuses are a mess. Eventual surgery. The price we pay."

Typically, before sinus surgery is considered in a patient who is suffering from recurrent sinus infections, a workup is required followed by maximal medical management.

A typical workup includes a CT sinus scan, allergy testing, and nasal endoscopy. If allergy testing is significant, aggressive allergy management is required prior to surgical consideration.

Depending on the CT scan and endoscopic findings, there are two "flavors" of sinus surgery: traditional and balloon sinuplasty.

In traditional sinus surgery, otherwise known as functional endoscopic sinus surgery, is when all sinus disease is physically removed endoscopically from the nose and sinus entrances are enlarged.

Balloon sinuplasty is when the sinus openings are enlarged using a balloon and can potentially be performed in the office assuming no anatomic contraindications (significant deviated septum, nasal polyps, etc).

Exactly what type of sinus surgery Nikki Sixx will pursue is not clear, but regardless of what method is selected, there will be a period of recovery afterwards which almost certainly will include saltwater sinus rinses.

Our office provides both sinus surgery options as well as in-office sinus surgery.

Source:
Nikki Sixx needs surgery for sinus problems. SFGate 6/28/12

R&B Singer Maxwell with Vocal Cord Hemorrhage

At least that's what the Washington Post reported on June 22, 2012. This has resulted in cancellation of his summer tour.

Per media reports, his vocal cords are swollen with hemorrhage.

Some fans may recall that something similar happened to Adele in winter of 2011 which resulted in her also canceling a number of engagements. She ultimately had surgery to correct her problem.

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. If a voice is present, it is much deeper than normal due to the additional "weight" of blood and edema (just like a violin string where the thicker the string, the deeper the pitch). There may even be mild pain associated with this occurrence.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in a vocal cord polyp or vocal cord scarring. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel.

For that, surgical intervention is required.

Such surgical intervention is much like trying to get rid of varicose veins in the leg.

One option is to precisely cut it out. Watch a video on this approach (video shows a vocal cord mass removal, but just pretend the mass is a blood vessel as the approach is identical).

The other option is use of a laser which is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision (though not zero). Shown below is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser.

Read more about laser treatment of vocal cord pathology here.

Read the Washington Post story here.

Oral Mass Excised From Fetus Still in the Womb!

In a world's first, surgeons removed a 4 cm oral mass (teratoma) in a 4 month old fetus while still in the womb. This was performed at the University of Miami Hospital.

A cannula was inserted through the mother's belly and into the womb where it was directed to the mass under ultrasound and endoscopic guidance. Via this cannula, a laser was used to lop the mass off free.

A healthy baby was born 5 months later and is now a healthy, normal 20 month old child.

A more common variation of this procedure is what is known as an "exit procedure". In an exit procedure, a cesarean section is performed and while the newborn is still connected via umbilical cord, all necessary procedures are performed before the cord is cut and the newborn fully delivered.

Needless to say, performing surgery while still in the womb is an amazing feat of medical science and technology.

Kudos to the surgery team and the mother!!!

Reference:
Successful in utero treatment of an oral teratoma via operative fetoscopy: case report and review of the literature. American Journal of Obstetrics & Gynecology Volume 207, Issue 1 , Pages e12-e15, July 2012

Scientists Publish Research on Breakthrough Treatment for Tonsil Stones

Title sounds very exciting... even more so when I realized it was talking about the research paper that I co-authored with fellow ENT colleague Dr. Richard Thrasher on a new way of addressing tonsil stones.

I never really considered myself a "scientist,"but glad to hear that at least somebody considers me one!

This article apparently came out on MedicalXpress, a medical news website. It has also been picked up in a few other channels as listed under sources.

Source:
Scientists Publish Research on Breakthrough Treatment for Tonsil Stones. MedicalXpress 6/20/12

New Minimally Invasive Technique to Treat Tonsil Stones Developed by Dr. Chang. Fauquier ENT Blog. 6/14/20

Ear, Nose & Throat Journal publishes research on breakthrough treatment for tonsil stones. EurekaAlert 6/20/12


Reference:
Coblation cryptolysis to treat tonsil stones: A retrospective case series. Ear Nose Throat J. 2012 Jun;91(6):238-54.

New Minimally Invasive Technique to Treat Tonsil Stones Developed by Dr. Chang

Dr. Chang developed an innovative minimally invasive technique to treat tonsil stones using coblation technology. His findings have been published in this month's ENT Journal. In fact, his research made the front cover of the journal! Dr. Richard Thrasher of ENT Centers of Texas was a co-author in the study.

This technique called coblation tonsil cryptolysis is unique in that it can be performed in adult patients without sedation using only local anesthesia, much like laser tonsil cryptolysis. As with laser cryptolysis, pain is significant for only a few days and most adults can resume normal diet and activity within 1 week. In contrast, tonsillectomy entails significant morbidity for several weeks. However, coblation avoids the significant disadvantages of laser use, including the potential for airway fire, retinal damage from reflected scatter, dealing with plume from vaporized tissues, oral/facial burns, and the high cost of purchasing and maintaining laser equipment. After a single session of coblation tonsil cryptolysis, a significant decrease and even elimination of tonsil stones can potentially be achieved.

Read more about this mode of treatment here.

Read the research article here.

12 Years Old Girl Dies After Tonsillectomy

Tampa Bay Times reported on June 10, 2012 a 12 years old girl died after a tonsillectomy performed on Aug 13, 2010 for chronic tonsillitis. From the details provided from the news report, it seems that several independent issues all contributed together that lead to this child's unfortunate and tragic death.

This case was also complicated by subsequent non-medically related actions taken by medical personnel which will not be discussed here.

Strictly medically speaking...

Local Anesthetic With Epinephrine

It is unclear exactly when the local anesthetic bupivacaine (Marcaine) with epinephrine was injected into the tonsil region which may help with post-tonsillectomy pain control in the pediatric population. Also unclear is what concentration and how much got injected.

However, it is far from common practice (though not rare) and it is not something I personally inject in the pediatric population for a few reasons in spite of its well-known suspicion to minimize a sore throat after surgery. (There are plenty of papers that report such injection offers NO additional pain control in children. See references below.)

1) The risk of bupivacaine is toxicity to the heart leading to arrhythmias that may ultimately lead to a heart attack.
2) Epinephrine can result in hypertension as well as further exacerbate cardiac problems

Given report of "bloody froth" in the endotracheal tube along with acute onset of tachycardia and hypertension, I suspect the child suffered from pulmonary edema, most likely secondary to accidental intra-vascular injection of the local anesthetic (causing cardiac failure) and epinephrine (causing tachycardia and hypertension).

Given these risks and fact that kids are so much smaller and more susceptible to medication risks, I personally never inject this medication during/after tonsillectomy. Even in adults, I never inject routinely, though I do offer to adults undergoing tonsillectomy (but than I use bupivacaine alone without epinephrine).

The hypertension itself led to problem #2...

Congenital Cerebellar Vascular Anomaly

The child had a congenital cerebellar vascular anomaly that ruptured leading to a life-threatening bleed in the brain.

In and of itself, this anomaly would not have been a problem, but given the reported sudden hypertension, the rupture is akin to inflating a tire with too much air causing it to pop.

Most likely, if the child's cardiovascular compromise never occurred, this bleed never would have happened in the first place.

It's also entirely possible if the local anesthetic was never used, this death would not have happened as well.


Source:
Lawsuit claims doctors' mistakes caused Palm Harbor girl to die after tonsillectomy. Tampa Bay Times 6/10/12.


References:
Comparison of clonidine, local anesthetics, and placebo for pain reduction in pediatric tonsillectomy. Arch Otolaryngol Head Neck Surg. 2011 Jun;137(6):591-7. Epub 2011 Mar 21.

Preincisional bupivacaine in posttonsillectomy pain relief: a randomized prospective study. Arch Otolaryngol Head Neck Surg. 2002 Feb;128(2):145-9.

Control of early postoperative pain with bupivacaine in pediatric tonsillectomy. Ear Nose Throat J. 1993 Aug;72(8):560-3.

daVinci Surgical Robot Makes Paper Airplane... Yawn!

A blog reader of mine informed me about this YouTube video of a surgeon, Dr. James Porter, making a paper airplane using a daVinci surgical robot.

For those unawares, the daVinci robot is used to assist the surgeon in "difficult-to-reach" procedures. It is used in the fields of urology, ENT, gynecology, and general surgery.

There is much debate whether the daVinci robot really is worth it.

This paper airplane video is a perfect example of why it is NOT worth the $1.3 million price tag.

Why?

Because I can make a paper airplane with my own two hands that is just as good as the one made by the robot... and I can do it faster and WAY more cheaply.

I should also point out that the paper airplane made by the robot couldn't even fly...

NOW... what would have been a much more impressive video and would highlight specifically what the daVinci robot can do that a human would not have been able to do is to make a paper airplane INSIDE of a wine bottle.

Costs of Surgery... How Is This Calculated?

So I have blogged about this topic a few times in the past, but there still seems to be confusion regarding the costs of surgery.

As mentioned in the past, the cost of surgery is broken down into basically 3 separate charges:

• Surgeon's charge
• Anesthesia's charge
• Hospital's charge

So... after surgery, a patient typically will get 3 bills; one each from surgeon, anesthesia, and hospital.

At least in the United States, the three charges are completely separate from each other to the point that anesthesia will have no idea what the charges for the surgeon as well as hospital will be.

Same goes for the surgeon... the surgeon will know his charges, but will have no idea what the charges will be for anesthesia and the hospital.

Even if the surgeon demands to know what anesthesia and the hospital will charge for a surgical procedure (s)he will perform, a specific charge will not (can not) be provided in the United States typically.

Why is that?

If I am going to perform for example, a tonsillectomy, why can't anesthesia give even me the surgeon a specific dollar amount of what anesthesia will charge? Why can't the hospital administration provide me the hospital charges?

Here's why... or at least part of the reason why in the United States...

Surgeon's Charge

The surgeon's charge is set. For a given surgeon, his/her charge will remain the same regardless of time or difficulty of the surgery. It may be different between different surgeons... but for a given individual surgeon, it will always be the same for a given procedure.

For example, if the surgeon's tonsillectomy charge is $250. It will remain $250 whether it takes 15 minutes or 3 hours. It will remain $250 if the surgery was technically difficult or a piece of cake.

So, the surgeon's charge is easy. It is what it is.

The harder question to answer is what the anesthesia and hospital charges will be...

Anesthesia Charges

Anesthesia charges on a per time basis (in increments of 15 minutes) on top of a "base" charge that depends on the surgical procedure.

For example, let's say a given anesthesia group has a base charge of $500 for tonsillectomy.

Let's also assume this particular anesthesiology group charges $500 per 15 minutes of anesthesia.

SO... if the surgeon performs a tonsillectomy and it takes the surgeon 30 minutes to perform the procedure, the anesthesia charge will be $500 base charge PLUS $1000 for the time ($500 per 15 minutes) for a total anesthesia charge of $1500.

If it so happens that the surgery takes only 15 minutes... than the anesthesia charge will be $1000 ($500 base charge plus $500 for the 15 minutes surgical time).

In other words, for the SAME exact surgical procedure, the anesthesia charges may be different for different patients depending on how long the surgery takes.

Hospital Charges

Different hospitals calculate their charges differently... but in essence, the hospital will charge whatever it cost them to allow the surgery to happen in their facility plus a nebulous "profit" factor.

SO, a given hospital charge will include the:

• Salary of all the personnel used in the surgery (surgical tech, registered nurse, circulating nurse, anesthesia tech, secretary, etc)
• Equipment used during the surgery (IV lines, needles, anesthesia tubing, masks, endotracheal tube, surgical equipment, etc)
• Medications used during the surgery (gases, IV drugs, etc)
• Facility costs expended during the surgery (electricity, water, oxygen, medical waste disposal, etc)

To take the example of tonsillectomy, the hospital charges will include all the equipment, medications, personnel, and facility costs utilized during the tonsillectomy surgery.

In Summary, the Cost of Surgery is... It Depends

Given anesthesia charges vary based on the time duration of surgery regardless of WHAT the surgery is as well as hospital charges which may vary based on how much was "expended" during the surgery regardless of WHAT the surgery is, the anesthesia and hospital charges are moving targets which roughly correlate with how long the surgery takes.

The surgeon can certainly state what their charges will be up-front because this charge is fixed, but anesthesia and hospital charges are NOT fixed and depend on a certain time factor regardless of WHAT surgical procedure is being performed.

Because of this time dependence, that's why anesthesia and hospital charges can not typically be obtained prior to surgery in most places.

That's also why most places can't (won't) post the total cost of surgery up-front.

Of course, if a given surgeon is very consistent and always takes 15 minutes to perform surgery and always uses the same exact equipment, than anesthesia and the hospital may be able to provide an "averaged" charge up-front.

It is also not uncommon that additional "discounts" may be offered based on a patient's income.

Some places like the Surgery Center of Oklahoma somehow persuaded the anesthesiologist, surgeon, and facility administrators to sit around a table and force an agreement on a fixed TOTAL charge for different surgical procedures. Once an agreement is made on a fixed charge for each, an up-front cost can be publicized... but this can never happen as long as anesthesia and hospital refuses to agree to a fixed charge and rather stick with a time-based framework to determine their charges.

Surgery Center Posts Prices of Procedures

Given the uproar over the lack of transparency of surgery prices, it was only a matter of time before an operating facility in the United States (oversea facilities have already done so) takes the step of posting the cost of surgery... a set cost that is exactly what a patient pays. Complete cost transparency.

The Surgery Center of Oklahoma is an AAAHC accredited facility since 1998 and has over 40 participating surgeons. And they are the first that I'm aware of that has taken the step of posting the cost of surgery on their website. The caveat being the cost shown ONLY applies to those who do not have health insurance.

On their website, they state:

"Transparent, direct, package pricing means the patient knows exactly what the cost of the service will be upfront. Fees for the surgeon, anesthesiologist and facility are all included in one low price. There are no hidden costs, charges or surprises."

Keep in mind that this cost is NOT just the surgeon's fee, but also includes the anesthesia charges as well as facility charges. Read more about such charges here.

So what are the charges? They have it all posted on their website!

But below is a list of charges for ENT procedures as of 6/3/12 (surgeon, anesthesia, and facility charges all bundled into a single charge). The webpage also includes prices for general surgery, orthopedics, urology, ophthalmology, etc.

I wonder if other facilities in the United States will start following suit???

Neck
Thyroidectomy		$ 6,160.00
Lymph Node Excision / Biopsy		$ 2,255.00
Ear
Myringoplasty		$ 2,400.00
Bilateral Myringotomy with tubes		$ 1,700.00
Tympanoplasty		$ 5,060.00
Tympanoplasty - Mastoidectomy		$ 7,050.00
Mastoidectomy		$ 6,640.00
Inner Ear - Stapedectomy		$ 5,390.00
Ossiculoplasty		$ 5,060.00
Cochlear Implant		$ 8,800.00
Foreign Body Removal		$ 1,500.00
Nose
Bilateral SMR Turb		$ 2,700.00
Sinus / Turbinates 1 side		$ 3,795.00
complex		$ 4,950.00
Sinus / Turbinates both sides		$ 4,510.00
complex		$ 5,885.00
Septoplasty		$ 3,550.00
Septoplasty and Sinus/Turbinates		$ 5,060.00
Nasal Fracture Simple Closed		$ 1,900.00
Nasal Frature Complex Open		$ 4,015.00
Throat
Tonsillectomy		$ 3,050.00
Adenoidectomy		$ 2,695.00
Tonsillectomy and Adenoidectomy		$ 3,695.00
Adenoidectomy and BMT		$ 3,300.00
Tonsillectomy and Adenoidectomy and BMT		$ 4,400.00
Frenulectomy		$ 1,600.00
Uvulopalatopharyngoplasty		$ 5,445.00
Diagnostic Laryngoscopy with biopsy		$ 2,970.00